Provider Demographics
NPI:1275738668
Name:A TO Z CHILDREN'S DENTAL CLINIC, LLC
Entity Type:Organization
Organization Name:A TO Z CHILDREN'S DENTAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCELLUS
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-876-1065
Mailing Address - Street 1:805 E HIGH ST
Mailing Address - Street 2:PO BOX 638
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2448
Mailing Address - Country:US
Mailing Address - Phone:505-876-1065
Mailing Address - Fax:
Practice Address - Street 1:805 E HIGH ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2448
Practice Address - Country:US
Practice Address - Phone:505-876-1065
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1966261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ9089Medicaid
NM8615Medicaid